Structure & Function of the Heart:
Risk factors for Coronary Artery disease:
Coronary Artery Disease:
Emergency Complications of Heart Attack:
Coronary Artery Bypass Grafting (CABG):
Rheumatic Fever and Heart Valve Diseases:
Heart Transplantation and Assisted devices
Acute Coronary Syndromes (New name for heart Attack)
Acute coronary syndrome” (ACS) is defined as sudden reduction in blood flow to the heart muscle caused by a narrowing or blockage of the blood vessels. This can result in an impending heart attack (unstable angina) or an actual heart attack (myocardial infarction). When a heart attack occurs, blockage of blood flow to the heart causes damage and death to the heart muscle and leaves a scar tissue.
Typical signals of an impending heart attack include angina that is more severe or lasts longer than a few minutes. The chest discomfort associated with a heart attack, or myocardial infarction, may last for several hours (longer than a usual angina episode) and may not respond to nitroglycerin tablets, or even intravenous nitroglycerin at the hospital. Heart attack victims may require intravenous morphine or other drugs to relieve the pain. Although heart attack symptoms are usually clear, heart attack victims may not experience any angina and may “just not feel well.” In some cases, patients report a sudden onset of heartburn and shortness of breath. These are often explained away as merely indigestion and only later will the actual cause become clear. Sometimes heart attacks are even discovered long after they have occurred, and, in retrospect, patients recall no symptoms at all.
What should I do?
If you think of having a heart attack, call 911 or report immediately to the emrgency room. If the doctors think you might have ACS, they will start their clinical assessment with concentration on the following points:
You should also receive some diagnostic tests to help the doctors find out if you are having a heart attack:
Electrocardiogram (ECG) – which evaluates the electrical activity of your heart by putting electrodes on your body and connecting these to a recording machine. The machine records the pattern of activity of your heart. Particular patterns are associated with ACS.
Troponin blood test – your doctor should take blood from you within 12 hours from the start of your symptoms to check your blood troponin concentration. Troponin is a protein found in heart muscle cells. It leaks into your blood when heart muscle is damaged. This happens if you have had a heart attack.
What treatments should I receive straight away?
Within 12 hours of your first symptoms, you may be given some of the treatments listed below:
Aspirin therapy: You should be given aspirin immediately. Aspirin will help prevent your blood from clotting.
Combination aspirin and clopidogrel therapy: You should be treated immediately with both aspirin and a drug called clopidogrel [plavix] if: there is a change in your cardiac rhythm; or your troponin level is raised.
Glycoprotein llb/lla receptor antagonist: If the doctors think that you have a high risk of having a heart attack, you should be given a drug called glycoprotein llb/lla receptor antagonist. This will be given to you as a drip, directly into your veins. This drug is also used if you are going to have a procedure called percutaneous coronary intervention (PCI), which helps to widen your arteries.
Anticoagulant therapy: Anticoagulants are another kind of drug that help to reduce the risk of blood clots forming. If you have changes in heart rhythm, you should be treated with either:
low molecular weight heparin: You should take this drug for eight days or until you leave hospital or have a procedure called coronary revascularisation.
Beta blockers: Beta blockers will help to stop you having either another attack of angina or a heart attack. They can also reduce your risk of dying. You should not be treated with beta blockers if you have: low blood pressure; or a slow heart rate.
Cardiac monitoring: Your heart rhythm should be monitored so that doctors can see if there are any other problems with how your heart is beating. This is called continuous cardiac rhythm monitoring.
Oxygen: You may be given oxygen to help relieve your symptoms and to reduce the risk of damage to your heart muscle.
Primary percutaneous intervention (PCI):
You may have a procedure called PCI to widen your narrowed artery. In this procedure a catheter (a thin hollow tube) with a small inflatable balloon at its tip is passed into an artery in either your groin or your arm. The operator uses x-rays to direct the catheter to a coronary artery until its tip reaches the narrowed or blocked section. The balloon is then gently inflated so that it squashes the fatty tissue responsible for the narrowing. This widens the artery so blood can flow more easily. Inside the catheter there is a short tube of stainless steel mesh, called a stent, which is left in place to hold open the narrowed blood vessel. When you have this procedure you should also be treated with a glycoprotein llb/llla receptor antagonist. This can help relieve your pain and reduce the chances of blood clots completely blocking your arteries.
Thrombolytic drugs (clotbusters):
If it is not possible to offer you PCI within 90 minutes of making your diagnosis, you should receive immediate thrombolytic drugs. This is a treatment which helps to dissolve any blood clots that may be blocking your arteries. Side effects of thrombolytic drugs can include nausea, sickness and bleeding. Bleeding is usually limited to the site of injection but bleeding from other areas of your body may occur.
After the first 12 hours have passed what other treatments will I need?
Revascularisation: Revascularisation is the term for a range of procedures that are used to unblock narrowed arteries. If doctors think that you have a strong chance of having angina or a heart attack again, then you should have coronary angiography and revascularisation. Coronary angiography is a procedure where a catheter (small hollow tube) is inserted into your groin or arm and directed through your blood vessels. A dye is then put down the catheter into the blocked arteries and an x-ray is taken to give the doctors pictures showing where your blood vessels are narrow. Revascularisation is the term for a range of procedures that are used to unblock narrowed arteries. If you have been treated with thrombolytic drugs, you should be considered for early angiography and revascularisation.
Angiotensin converting enzyme inhibitors (ACE inhibitors): You should be started on long term ACE inhibitor therapy within 36 hours of the attack if you have: Had A Heart Attack; Unstable Angina; Or Damaged Heart Muscle. ACE inhibitors help to lower your blood pressure and to reduce the work your heart has to do to pump blood around your body.
Antiplatelet or aspirin therapy
You should continue to take aspirin. This is called long term aspirin therapy. A dose of 75-150 mg is recommended.
Beta blockers and anti-anginal therapy: If you have unstable angina or signs of damage to your heart muscle or if you have had a heart attack, you should be given long term beta blocker therapy. If you continue to have symptoms of angina or have signs of heart failure then you should be given drugs called nitrates to relieve your pain.
Clopidogrel: Depending on the type of ACS you have, you should take clopidogrel for four weeks to three months. Your doctor will tell you when to stop taking this.
Statins: A statin is a drug that helps to lower your cholesterol levels. You should be started on a long term statin before you are discharged from hospital.
How will complications of Acute Coronary Syndrome be treated?
Breathing difficulties: Sometimes patients with ACS develop a collection of fluid in their lungs. This is called pulmonary oedema. This may leave you with shortness of breath and doctors should discuss with you whether or not you might need to have assisted ventilation. This is when a mask is placed over your nose and mouth so that you can be given oxygen to make your breathing easier.
Low blood pressure/damaged heart muscle: Sometimes patients with ACS experience a sudden drop in blood pressure (hypotension) and blood flow around their body. If this happens your heart is said to be in cardiogenic shock. The treatment for this is called intravascular volume loading and inotropic therapy. This means that the doctors will use a drip to give you special fluids (called inotropic fluid) to increase the volume of fluid that is circulating around your body.Your doctors may consider using a technique called intra-aortic balloon pump counterpulsation if your ACS is complicated by: Cardiogenic shock; Ruptured heart muscle; or Persistent pain.
Intra-aortic balloon pump counterpulsation is used to increase blood flow to your heart muscle and to reduce the workload for your heart. The pump will be placed inside your aorta, which is the main artery that carries oxygen-rich blood to the rest of the body.
If you have low blood pressure due to the left side of your heart failing, you should be considered for immediate coronary revascularization. If you have suffered severe damage to your heart muscle, then you may have a physical problem such as a ruptured muscle which is preventing your heart from working. If this is the case then you should be considered for surgery to put this right within 24-48 hours of your heart attack.
Symptoms and signs of heart disease:
NonInvasive diagnostic tests For heart disease:
Invasive Diagnostic Tests for heart disease:
Cardiac Arrythmias and Pacemakers:
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